Do you know what the leading cause of death in the United States is? Heart diseases. For many years, heart diseases have been at the top of the list and, by estimates, will remain on top for many more years. This makes cholesterol testing an important tool for the prevention and management of cardiovascular issues. There are over 86 million adults above the age of 20 in the USA who have total cholesterol levels above 200 mg/dL. This prompts serious concern. So, the need for accurate lipid testing is undeniable.
In many cases, simply measuring cholesterol isn’t enough, and complete lipid profiles are required. CPT code 80061 is a billing code that billers use for lipid panels. However, many billers make mistakes while claiming reimbursements against 80061. That is why we have compiled this comprehensive guide. So, let’s start.
CPT Code 80061 – Description
CPT code 80061 is used to bill a lipid panel test. A lipid panel is simply a blood test that measures the levels of fats (lipids) in your bloodstream. It is a bundled laboratory test and measures essential lipid components.
Lipid panel tests are very common in cardiology and are widely used to evaluate heart health and help develop a treatment plan.
The four essential components measured under CPT code 80061 are:
- Total cholesterol (CPT code 82465): The total amount of cholesterol circulating in your blood.
- Low-density lipoprotein (LDL) cholesterol (CPT code 83721): Known as “bad” cholesterol, LDL increases the risk of heart disease and stroke.
- High-density lipoprotein (HDL) cholesterol (CPT code 83718): Known as “good” cholesterol, HDL helps clear excess cholesterol from your arteries.
- Triglycerides (CPT code 84478): A type of fat that, when elevated, can increase the risk of heart disease.
The calculation of the LDL component is not straightforward. Rather, from the results of the other three lipid components, low-density lipoprotein is calculated using the Friedewald equation:
LDL = Total Cholesterol – HDL – (Triglycerides / 5)
However, an important point that many billers miss is that LDL is calculated using the above-mentioned method if the triglyceride levels are below 400 mg/dL. If the levels exceed 400 mg/dL, then LDL is measured and billed separately under CPT code 83721.
The lipid panel test is simple and requires a small blood sample. However, despite its simplicity, it is one of the most important and frequently performed pathological tests.
Scenarios Where CPT Code 80061 is Applicable
To better understand the practical usage of CPT code 80061, let’s look at a couple of real-world scenarios in which it can be used:
Cardiovascular Risk Assessment
Many cardiovascular diseases are long-lasting and require strict maintenance. Patients with multiple cardiovascular risk factors, including hypertension, diabetes mellitus, smoking history, or family history of premature cardiovascular disease, require lipid assessment. However, not all patients require a complete lipid test. Based on different scenarios, healthcare providers may opt for panel tests under 80061 or individual assessments of components.
Pre-Operative Assessment
Surgical patients may require lipid assessment as part of a comprehensive pre-operative evaluation, particularly for major surgical procedures or in patients with known cardiovascular risk factors. This helps surgeons and anesthesiologists optimize pre-operative care and identify potential complications.
Applicable Modifiers for CPT Code 80061
You may append the following modifiers to CPT code 80061 when needed to ensure coding specificity and accurate reimbursements.
| Modifier | Description | When to Use |
|---|---|---|
| 59 | Distinct Procedural Service | When billing with procedures that are typically bundled. To indicate that the lipid panel test was distinct and medically necessary. |
| XS | Separate Structure | Alternative to modifier 59. Indicates a separate and distinct service when NCCI edits apply. |
| 90 | Outside Laboratory | Used when the test is performed by an outside laboratory, with billing handled by the ordering provider. |
| 91 | Repeated Clinical Diagnostic Laboratory Tests | When the same laboratory test is repeated on the same day for clinical reasons. |
| QW | CLIA-Waived Test | When a lipid panel is performed in a CLIA-waived laboratory setting. |
CPT Code 80061 – Billing & Reimbursement Guidelines
You must consider the following factors when billing for CPT code 80061, as it will help you prevent claim denials.
Complete Panel Requirement
CPT code 80061 should only be billed when all four components – total cholesterol, HDL, LDL cholesterol, and triglycerides – are tested. If fewer components are performed, individual codes (e.g., 82465, 83718, 84478) must be used.
Frequency Limitations
Medicare’s National Coverage Determination (NCD) specifies that a lipid panel is typically covered once annually for monitoring long-term therapy or following borderline cholesterol levels. Up to six tests may be covered in the first year of dietary or pharmacologic treatments if medically necessary. More frequent testing is allowed for significant elevations or therapy adjustments.
Medical Necessity
Even though lipid panel testing is simple and results in low reimbursement, insurance payers, especially Medicare, have restrictions on reimbursements. Medicare does not provide coverage for routine or preventive lipid disorder tests. Even if a lipid screening might be medically indicated, it is excluded from Medicare coverage by law. Lipid tests performed on individuals without symptoms are classified as screening, even if risk factors like family history or tobacco use are present.
So, it is essential to use CPT code 80061 only for approved ICD-10 diagnoses. Some of these include:
- E78.5: Hyperlipidemia, unspecified
- E11.9: Type 2 diabetes mellitus without complications
- Z13.220: Encounter for screening for lipoid disorders
- I50.9: Heart failure, unspecified
Wrapping Up
CPT code 80061 is a simple yet essential pathology billing code. Missing out on small details when filing insurance claims for 80061 may lead to denials and audits. By following the guidelines mentioned in this blog, you can successfully file your claims and receive fair reimbursement.
If you are facing frequent denials or bottlenecks in your billing operations, consider touching base with our billing experts at MediBillMD for the best pathology billing services.
